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• WELL/PUMP PERMIT <br /> 4 411:JQ%QUDACOUSTYENs'IRONMENTALREA4T17DEPARTMENT Mi E44T?t4,L%STREEr-SLOCKTOrCA9$M•(M)4W3420 <br /> .40?q-REFVNDAALF PERM[ Cr EXPIRES 1 YEAR FROJI DATE ISSRED <br /> 7MA00 ate ,/s.�° lec_-_7/ �lJ ZG _[rU GG Cn.1TaP__G��Eti, CIS 9Sz3 <br /> CROSS STREET V'' /�Q AP.N —V PAacEL.. f <br /> O"'ER NAME oI2 GoZo ops;) F.E, 2 2-_ '1_?3 <br /> _�•//.}�1/n�D���yJ ��f2/F//y/`3//C'�J/� �/ �LCJ�`L�/j���J//�'Y�� � � n�1?A5 <br /> Z 36OMTERADDRM 4` VYCf' � J <br /> C0914rR1CrOR PPIKINEE2.01F-997- <br /> COATMCfORADDRM W / i <br /> ctSz5 2— <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ fCliS/�SJfATEIZiP_ __ <br /> Lwmm O C-57 ) a D-09 a Other \t AIDER u / ExnR trlD%D..TE �Q <br /> t <br /> GEOGRAPHICALI\FOR:%IA1JQ%: Coordinates X Tewmhip__ RAR$e SectiaD <br /> 1NtESDt.D VsE Q DaDewc Pntat. NgMigattomAgnicuitwo D industrial C! E3 Soil Sarapling-Cha*a tzrizatiam 1 <br /> ❑Pmf,—, -Waaer SYstcm ` f <br /> mv :: "S"..%'..4 —V—,w iacc Vnsb� <br /> TYPE OF WORK a\e.t•Wr$ 0 Repbwmem Well o Well Altwmio M. Ddilkat1Qn Cl Test Hole ❑Otbcr <br /> a Monitoring Well(s) m:.�C q1 us 0 Soil Borin-las) ter �••[ptd�e, 0 Gecaeettnieal <br /> O Well Desnuc& o OW-0f-Srn ice Ki tt Q Ota-0i-Anicc Wc1l Rcrwnal <br /> O'CR Replacanca O P--pair Cl CrdsrConow on R. <br /> VVLLL c0\.TRLCriM <br /> tHiAint;JteWod o MW Rotary Q Air Roary o Ateger a Caw Tool ❑Push Potmt a Othtr <br /> Pr Mils d Wdi I)cpth ,ft EzcaAatlnn in diameter O Open Bottom ❑Gm%et Pack r Gravel Size -in diamcwr <br /> D CvD"or Casing in diameter / Conductor Coshrg Dcph R <br /> Well Casing Diumter_in Thickncss!Gaw_tc.'ASTM Sehzd O S:c l (3 Plastic a Staiole�s Stezl a Other <br /> Grout Seal 1);pth ri ❑Xcat Cement t94 lb bag:5-10,gai AvW) 0 Sand C.M= .tack tnir;7 sal water <br /> r Bentonite 42l;wipdsl p Vlastutenurer Spec« solids_"c \acre Cl Specs on Fitz O Specs Sabmgted <br /> Great PLuemeat ltpethed LIPumped Q FrocFall fl 01 O Retardant:Acc_crator(name) <br /> I PEDEST'm ,nsUllyd By Q rkdf.T a Pomp Contractor Q Other <br /> ❑Coacrete PedmW Dimeaslons: Widtb_ft Let "k in ❑Clrlsty Boa Q Store <br /> pvmp :7DDtersiblC f!ine OOther HP PtttttpSH rt StandiagWaaxLecl 0 <br /> WELL DESTRGCTto% a Open Bosom a Gmvol pack a Vocatcd G Other — t <br /> Wel,Diametzr_in Totai Depth__tI Dcprh Lo` =,T_ _h a Casing to .Puforatzd tion fl to $ <br /> Scaling Material Q\rat ccomt M 16 bog:S-IOffitrt wuttr/ ❑SaAd Ccx,= wk atft r 7 gal A-Aer 0 ikum to Fl-ttet; <br /> Q B.^nwnii.-1?0".a solids) o?tanufaenrrer Spx,�z solids 9A %AMC Q Specs on Fi.l: ❑Specs Submwzd <br /> PbEvromf Method ❑PWTWW G Free Fall O Other <br /> O Compte:o A ith Musbtoom Cap —ft below gtado a Comptete w Emsting Surfwc Pad <br /> flEREBV CERTUY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WOM TARL RE DOME V9 ACCORDANCE WITH SAN <br /> aOAOM COUN7V ORDI.\ANCES. STAT .AVD R=S AND REGULATIONS. I ALSO CERTIFY"THAT}IIY REQL%Mj)LICENSE LS <br /> CURRENT ANDA RV' 7 H ° A CONTRACTORS STATE LICENSE BOARD A\•D THAT I Ail LN CO3VLA&NC£WTTR ALL <br /> WORKERS CO_ <br /> SIGNED <br /> i i t RE YMFNT <br /> CE��FD <br /> _ N JUN 08 ?0?0 <br /> ENV Rp USN CO <br /> y� /✓J l,Se4ST4iEYT o Y qLT0Fpq TrAL y <br /> ApplicatiatAcrep[edBY-"— ; "�V Date JZ� Area y EmPloYee,D> Z)A __ Nt <br /> Grztn IaspeclioD D)• Date ® SPECIAL Well Perntft <br /> tbmpinsltcetionBy-_�Y'4r1[..SL.D (L�.t�tt �•.t:t1 Date ('D'1e ❑ 'I'JAIti'ERRee¢ired <br /> D:muction Inspection By Dam Constnms d Well Depth ^_ft <br /> CONDaN FS <br /> PE Sc Retd►ed _4mttuss Pettttaitl [RwaieC# Welt'@7t <br /> Codes lnlo Relented Sttnkx # <br /> 3 0 7 <br /> EHD 43-02.006 WPB R t!Permit tae f)a'arrr do. 1 <br /> 91 1,M07 <br />